DEPARTMENT OF SURGERY
DELINEATION OF PRIVILEGES FOR GENERAL SURGERY
NAME: _________________________________________
DATE: ____________________
Please check the “Requested” box for each privilege requested. Applicants have the burden of producing
information deemed adequate by the hospital for a proper evaluation of current competence, current clinical
activity and other qualifications and for resolving any doubts related to qualifications for requested privileges.
Other Requirements:
1. Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have sufficient
space, equipment, staffing, and other resources required to support the privilege.
2. This document is focused on defining qualifications related to competency to exercise clinical
privileges. The applicant must also adhere to any additional organization, regulatory, or
accreditation requirements that the organization is obligated to meet.
Qualifications for General Surgery
Initial privileges: To be eligible to apply for privileges in general surgery, the applicant must meet the
following criteria: Successful completion of an Accreditation Council for Graduate medical Education
(ACGME) or American Osteopathic Association (AOA) accredited residency in general surgery.
AND/OR
Current certification or active participation in the examination process leading to certification in general surgery
by the American Board of Surgery or the American Osteopathic Board of Surgery.
CORE PRIVILEGES: GENERAL SURGERY
 Requested
Admit, evaluate, diagnose, consult, and provide pre-, intra-, and postoperative care and perform surgical
procedures to patients of all ages to correct or treat various conditions, diseases, disorders, and injuries of
the alimentary tract; skin, soft tissues, and breast; endocrine system; head and neck; surgical oncology,
trauma, and nonoperative trauma; and the vascular system. May provide care to patients in the intensive
care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with
emergent conditions consistent with medical staff policy regarding emergency and consultative call
services. The core privileges in this specialty include the procedures on the attached procedures list and
such other procedures that are extensions of the same techniques and skills.
General Surgery Privileges
Approved by Dept. of Surgery: 7/17/12
Page 1
Non-core privileges: Colonoscopy with polypectomy
 Requested
Initial privileges: Successful completion of an accredited residency in general surgery that included
training in lower endoscopy procedures with a minimum of 50 procedures performed during training or
equivalent training and/or experience obtained outside a formal program that is at least equal to that
obtained within the formal residency program.
None-core privileges: Advanced laparoscopic procedures (e.g., colectomy, spenectomy,
adrenalectomy, common duct, exploration/stone extraction, donor nephrectomy and nissen
fundoplication (antireflux surgery))
 Requested
Initial privileges: Successful completion of an accredited residency in general surgery that included
advanced laparoscopic training or completion of a hands-on CME course.
None-core privileges: Stereotactic breast biopsy
 Requested
Initial privileges: Successful completion of training in the stereotactic- and ultrasound-guided technique of
breast biopsy during residency or in an accredited course or institution and possession of privileges for
breast imaging interpretation.
Non-core privileges: Sentinel lymph node biopsy
 Requested
Initial privileges: Successful completion of an ACGME or AOA residency in general surgery that included
training in sentinel lymph node biopsy or successful completion of a hands-on CME course and proficiency
in the standard diagnosis and surgical management of breast cancer.
CORE PROCEDURES LIST
This is not intended to be an all-encompassing procedures list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this
organization and inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do
not wish to request, and then initial and date.

Performance of history and physical exam
General Surgery Privileges
Approved by Dept. of Surgery: 7/17/12
Page 2
Trauma, abdomen, alimentary








































Abdominoperineal resection
Amputations, above and below the knee, toe, transmetatarsal, digits
Anoscopy
Appendectomy
Circumcision
Colectomy (abdominal)
Colon surgery for benign or malignant disease
Colotomy, colostomy
Correction of intestinal obstruction
Drainage of intra-abdominal, deep ischiorectal abscess
Emergency thoracostomy
Endoscopy (intraoperative)
Enteric fistulae, management
Enterostomy (feeding or decompression)
Esophageal resection and reconstruction
Distal esophagogastrectomy
Excision of fistula in ano/fistulotomy, rectal lesion
Excision of pilonidal cyst/marsupialization
Gastric operations for cancer (radical, partial, or total gastrectomy)
Gastroduodenal surgery
Gastrostomy (feeding or decompression)
Genmitourinary procedures incidental to malignancy or trauma
Gynecological procedure incidental to obdominal exploration
Hepatic resection
Hemorrhoidectomy, including stapled hemorrhoidectomy
Incision and drainage of abscesses and cysts
Incision and drainage of pelvic abscesses
Incision, excision, resection, and enterostomy of small intestine
Incision/drainage and debridement, perirectal abscesses
Insertion and management of pulmonary artery catheters (core?)
IV access procedures, central venous catheter, and ports
Laparoscopy, diagnostic, appendectomy, cholecystectomy, lysis of adhesions, mobilization, and
catheter positioning
Laparotomy for diagnostic or exploratory purposes or for management of intra-abdominal sepsis or
trauma
Liver biopsy (intraoperative), liver resection
Management of burns
Management of intra-abdominal trauma, including injury, observation, paracentesis, lavage
Management of multiple trauma
Operations on gallbladder, biliary tract, bile ducts, hepatic ducts, including iliary tract reconstruction
Pancreatectomy, total or partial
Pancreatic sphincteroplasty
General Surgery Privileges
Approved by Dept. of Surgery: 7/17/12
Page 3

















Panniculectomy
Protosigmoidoscopy, rigid with biopsy, with polypectomy/tumor excision
Pyloromyotomy
Radical regional lymph node dissections
Removal of ganglion (palm or wrist; flexor sheath)
Repair of perforated viscus (gastric, small intestine, large intestine)
Scalene node biopsy
Selective vagotomy
Sigmoidoscopy, fiberoptic with or without biopsy, with polypectomy
Small-bowel surgery for benign or malignant disease
Splenectomy (trauma, staging, therapeutic)
Surgery of the abdominal wall, including management of all forms of hernias, including
diaphragmatic and inguinal hernias, and orchiectomy in association with hernia repair
Thoracentesis
Thoracoabdominal exploration
Tracheostomy
Trtanshiatal esophagectomy
Tube thoracostomy
Breast, skin, and soft tissue
 Complete mastectomy with or without axillary lymph node dissection
 Excision of breast lesion
 Breast biopsy
 Incision and drainage of abscess
 Management of soft-tissue tumors, inflammations, and infection
 Modified radical mastectomy
 Operation for gynecomastia
 Partial mastectomy with or without lymph node dissection
 Radical mastectomy
 Skin grafts (partial thickness, simple)
 Subcutaneous mastectomy
 Endocrine system
 Excision of thyroid tumors
 Excision of thyroglossal duct cyst
 Parathyroidectomy
 Thyroidectomy and neck dissection
Vascular surgery
 Hemodialysis access procedures
 Peritoneal venous shunts, shunt procedure for portal hypertension
 Peritoneovenous drainage procedures for relief or ascites
 Sclerotherapy
 Vein ligation and stripping
General Surgery Privileges
Approved by Dept. of Surgery: 7/17/12
Page 4
ACKNOWLEDGMENT OF PRACTITIONER
I have requested only those privileges for which by education, training, current experience, and demonstrated
performance I am qualified to perform.
I also request the ability to do any procedure in an emergency situation. I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in
such situation my actions are governed by the applicable section of the medical staff bylaws or related
documents.
Signed: __________________________________________________ Date: ____________________
DEPARTMENT CHAIR’S RECOMMENDATION
I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant
and:
 Recommend all requested privileges
 Recommend privileges with the following conditions/modifications:
 Do not recommend the following requested privileges:
Privilege
Condition/modification/explanation
Notes:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Department Chair’s Signature: ____________________________________ Date: __________
General Surgery Privileges
Approved by Dept. of Surgery: 7/17/12
Page 5